Statutory Accident Benefits

Your Legal Rights Following an Auto Collision

Every automobile insurance policy in Ontario contains mandatory accident benefits coverage. A list of available benefits is set out in the Statutory Accident Benefits Schedule.

Do I have to be an occupant in an automobile to be eligible for no-fault accident benefits?
No. Pedestrians and cyclists who were injured in an accident involving a vehicle may also be entitled for no-fault accident benefits.

Who else is covered by No-Fault Accident Benefits?
In addition to the classes of people listed above i.e. passengers, pedestrians and cyclists, any member of your immediate family who was not involved in the accident may also be entitled to recover benefits if he or she suffers psychological or mental injury as a result of your accident.

How do I get access to no-fault accident benefits?
You must notify your insurance company within 7 days of the accident, or as soon after as is practicable, that you wish to apply for benefits and your insurance company must then promptly give you application forms. You must title the completed application forms with your insurance company within 30 days after receiving them from the insurance company.

If I miss the deadline of 30 days, can I still apply for benefits?
Most insurance companies will accept late applications if you have a reasonable explanation for the delay. However, it is always best to meet the 30-day time limit. No benefit is payable until a complete application is sent and approved by the insurance company.

I have some other insurance coverage, such as health and drug benefits, short term benefits and long term disability benefits, through my employer. Does the no-fault accident benefits coverage still apply?
Yes, however, you must go to those other benefit plans first and seek coverage. If these plans fail to cover all or part of your losses, then the no-fault accident benefits may be required to pay additional amounts.

Supplementary Medical Benefits and Rehabilitation Benefits

What kinds of expenses or services is my insurance company required to pay for?
The insurance company may be required to pay all of the reasonable expenses incurred as a result of your accident, including:
i) medical, hospital and nursing care, not covered by OHIP,
ii) chiropractic, psychological and occupational therapy,
iii) medication, prescription eyewear, dental devices and medical aids
iv) transportation over and above 50 kilometers to and from treatment sessions,
v) social and vocational rehabilitation,
vi) home renovations and vehicle modifications.

Are there limits on what I can receive for medical and rehabilitation expenses?
As of September 1, 2010, new limits on medical and rehabilitation expenses apply.

Minor injuries will be eligible for $3500 in medical and rehabilitation services. More serious injuries (but not catastrophic injuries) as defined below, will be eligible for up to $50,000 in medical and rehabilitation expenses for up to ten years after the collision. Optional coverage is available and may apply if you purchased it to increase the amounts to $100,000 or $1,100,000. However, optional coverage does not increase the maximum amount for minor injuries.

If your injury is considered catastrophic (see below), then you may receive up to $1,000,000 in medical and rehabilitation benefits over your lifetime. Optional coverage may increase this amount by an additional $1,000,000.

What do I need to do in order to get treatment? What does my insurance company require?
You must submit a Treatment Plan for the insurance company.

This should be done before any treatment commences. The treatment plan must be prepared by a health professional or a social worker and signed by one of the following health practitioners:
i) physician, including your family doctor
ii) psychologist
iii) physiotherapist
iv) dentist
v) optometrist
vi) chiropractor
vii) registered nurse
viii) speech language pathologist

Insurance companies are entitled to refuse to pay for treatment unless a treatment plan is completed.

Attendant Care Benefits

Is my insurance company required to pay for an aide or attendant to help me at home?
If you have been injured in an accident, your insurance company may be required to pay the cost of providing for an aide or attendant. As of September 2010, these benefits can include the services of one of your family members caring for you at home only if they are ordinarily employed as an attendant providing those services or if they suffer an economic loss as a result of providing the services. The insurance regulations have special forms which can be completed by an occupational therapist or physician for this benefit.

How much can I receive for attendant care?
You can receive up to $3000 per month in attendant care for two years, up to a maximum of $36,000. If you have purchased optional coverage, you can receive up to $72,000 or $1,072,000.

If your injury is catastrophic, you can receive up to $1,000,000 for attendant care.

Treatment

Can I arrange for my own medical or rehabilitation assessment to determine what treatment I need?
Yes. Your own treating health care specialists can perform an assessment under the regulation and in most cases, the insurance company is obligated to pay for the cost of that assessment.

Funeral and Death Benefits

If a family member dies in an accident, what expenses is the insurance company required to pay for?
When an insured person dies as a result of a motor vehicle accident, the insurance company may be required to pay funeral expenses incurred up to a maximum of $6000.

Are there other payments that the family may be entitled to receive if someone dies in an accident?
Each person that was a dependent of the deceased is entitled to receive $10,000. If the deceased was married, a sum of $25,000 would be payable to his or her spouse. If the deceased was not married bur was survived by a dependent(s), the $25,000 is then divided equally among the dependents. If the deceased has a dependent at the time of the accident, $10,000 would be payable to the person upon whom the deceased was dependent.

What do optional death and funeral benefits include?
If you have purchased optional death and funeral benefits, the benefit for loss of a spouse is $50,000, the loss of a dependent, $20,000, and a maximum amount of $8000 for funeral expenses.

Weekly Income Replacement Benefits (Specified Benefit)

When am I entitled to receive weekly income replacement benefits?
You are entitled to receive weekly income replacement benefits (excluding the first week) after a collision in the following circumstances:
i) you were employed on the date of the accident and thereafter suffered a substantial inability to perform the essential tasks of your employment
ii) you were not employed at the time of the accident but worked at least 26 of the 52 weeks before the accident (or were receiving EI benefits at the time of the accident) and thereafter suffered a substantial inability to perform the essential tasks of the employment in which you spent most of your time during the 52 weeks before the accident.

When can I begin receiving income replacement benefits?
You will not receive income replacement benefits for the first 7 days after a collision. Then, as long as you qualify, you can receive 70% of your gross weekly income less any benefits you may be entitled to from other insurance policies or employment plans.

What is the maximum amount of income replacement benefits I can receive?
You can receive a maximum of $400 per week. If optional coverage was purchased, you can receive $600, $800 or $1000 per week. If you are entitled to Group Benefits or private benefits you will still be entitled to up to $400 in addition to the Group Benefits.

As a self-employed person, can I receive income replacement benefits?
Yes. Self-employed persons are entitled depending on their income and expense situation. Usually an accountant will have to calculate your entitlement.

For how long can I receive these benefits?
If you qualify, these benefits are available to you up to age 65 and then they start to reduce on a gradual basis.

Non-Earner Benefits (Specified Benefit)

When am I entitled to receive “non-earner benefits”?
If, at the time of the accident, you were not working but were enrolled in school or had completed your education during the year prior to the accident and were not employed in a job that reflected your education, you may be entitled to a non-earner benefit. You are only entitled to this benefit if you suffer a complete inability to carry on a normal life and are over 16 years old.

What is the maximum amount of non-earner benefit I can receive?
The amount of the non-earner benefit is $185 per week. However, nothing is payable for the first 26 weeks after the accident. If you were enrolled in school or had completed your education in the year prior to the accident, you are entitled to a non-earner benefit in the amount of $320 per week after the first 104-week period has expired.

Caregiver Benefits (Specified Benefit)

When am I entitled to receive “caregiver benefits”?
You may be entitled to a caregiver benefit if your injury is considered to be catastrophic and you were living with and were the primary caregiver for a person in need of care and were not being paid for these activities.

What is the maximum amount of caregiver benefits I can receive?
The maximum amount of the caregiver benefit is $250 per week for the person – catastrophic injuries only. If you purchased optional coverage, you can receive the caregiver benefit ($250 per week for the first dependent plus $50 for each additional dependent) regardless of the injury you have sustained.

Can I receive income replacement benefits, non-earner benefits and caregiver benefits all at the same time?
No. Only one of the income replacement, non-earner and caregiver benefits is payable for any given period of time. Advice from a knowledgeable lawyer may be needed to make the correct decision.

When can the insurance company stop payment of your specified benefits such as income replacement, caregiver and non-earner benefits?
Your insurance company may stop payment of weekly benefits in the following cases:
i) you failed or refused to submit the completed disability certificate
ii) you failed to attend the insurance company examination or provide reasonable information for the assessment
iii) the insurance company’s report states you no longer suffer your disability

How will attempting to return to work affect my weekly benefits?
You may attempt to return to work at any time during the first 104 weeks after the accident without affecting your entitlement to start receiving income replacement benefits if you cannot continue with the employment because of the accident.

When is your insurance company not obligated to pay benefits?
Your insurance company is not obligated to pay income replacement benefits, non-earner benefits, lost education expenses, expenses of visitors or home maintenance expenses if you were the driver of an automobile at the time of the accident and:
i) knew or ought to have known that the automobile was not insured or
ii) were not licensed to drive
iii) were an excluded driver under the contract of insurance for the vehicle which you were driving at the time of the accident
iv) were driving a vehicle, or were an occupant of a vehicle, when you ought to have known that the vehicle was being driven without the owner’s consent
v) were convicted of impaired driving
vi) were convicted of driving with a blood alcohol level exceeding legal limits
vii) were convicted of failing to provide a breath sample
viii) were engaged in, or were an occupant of an automobile that was being used in connection with a criminal offence
ix) misstated facts to the insurance company in order to obtain motor vehicle insurance
x) any person who is convicted of a criminal offence or is an occupant of a vehicle being used for the commission of a criminal offence.

Expenses of Visitors

Who is entitled to receive payment for “visiting expenses” incurred while I am injured?
If your family members and other individuals who were living with you at the time for your accident visit you, they are entitled to payment of all reasonable and necessary expenses included as a result of the accident during your treatment or recovery. There is no payment after 104 weeks unless the injury is catastrophic.

Lost Education Expenses

When am I entitled to receive payment for lost education expenses?
If you are unable to continue in a program that you were enrolled in at the time of the accident, the insurance company will pay for lost educational expenses.

What is the maximum amount I can receive for lost education expenses?
The maximum amount you can receive is $15,000. This amount is meant to compensate for expenses incurred before the accident, such as tuition, books, equipment, and room and board.

What is the maximum amount I can receive for housekeeping and home maintenance expenses?
You can receive $100 per week for all reasonable expenses for housekeeping and home maintenance, if your injury is considered to be catastrophic. If you purchased optional coverage, you can receive $100 per week for all reasonable expenses for housekeeping and home maintenance, regardless of the injury you have sustained.

How long can I receive payment for these expenses?
Your housekeeping and home maintenance expenses are paid for up to 104 weeks unless the injury is catastrophic.

What other expenses can I receive payment for from my insurance company?
Your insurance company may be obligated to replace or repair clothing damaged in the accident, prescription eyewear, dentures, hearing aids, prostheses, and other medical or dental devices lost or damaged in the accident.

Catastrophic Impairment

What is a “catastrophic” impairment?
Various injuries may be considered catastrophic by medical experts who conduct these assessments. Some examples of catastrophic impairments are paraplegia, quadriplegia, permanent loss of a limb, loss of vision in both eyes, and certain brain injuries. Where you do not meet one of these tests, once your condition has stabilized or two years has elapsed since the accident, you may make an application to your insurance company for a determination that the impairment is catastrophic.

What benefits am I entitled to if my injury is considered to be “catastrophic”?
If your injury is defined as a catastrophic impairment by the Insurance Act, you are entitled to a much higher level of medical and rehabilitation benefits and attendant care benefits (a maximum of $1,000,000 for medical and rehabilitation benefits and $1,000,000 for attendant care benefits).

These benefits are payable over your entire lifetime.

Medical Examinations

Can the insurance company require me to go to their doctor or other health care worker for a physical or psychological examination?
Yes. To assist an insurance company to determine if an insured person is entitled to a benefit, the insurance company may “as often as reasonably necessary” require the insured person to be examined. However, an insurance company may not require an injured person to attend an insurance examination (IE) with respect to an application for a benefit that is provided under the Minor Injury Guidelines.

Do I have to attend an examination before an application for no-fault accident benefits is submitted?
No, unless you request or consent to the examination in order to obtain certain benefits before you submit your application for accident benefits.

Optional Benefits

What if I have optional benefits?
Ensure that you contact your insurance company or a lawyer to determine what optional benefits you have purchased.

Claiming Benefits

What steps must I take when claiming benefits?
You must notify your insurance company within 7 days from the date of the accident that you want to apply for benefits and your insurance company must then promptly give you application forms. You must file the completed application forms with your insurance company within 30 days after receiving them from the insurance company. If you cannot do so within 30 days because of the severity of your injuries, the application must be made as soon as reasonably possible. You must also consent to the disclosure of medical information and/or loss of income information to your insurance company to obtain this information directly from your doctor and/or employer.

If you are having difficulties recovering the benefits you are entitled to, a lawyer should be consulted. Any lawsuit, to enforce the payment of these benefits, must be commenced within two years from the time the insurance company refused to pay the benefit (and only after a mediation has taken place) or within 90 days after the mediator reports to the parties.

Do I need a lawyer for either my lawsuit or my no-fault accident benefits?
A lawyer can help assess whether or not you have a potential lawsuit. A lawyer can also assist in ensuring that you receive the proper no-fault benefits.

Settlement Regulation

Can a no-fault accident benefits claim to be settled on a lump sum basis?
Yes. However, in most cases these cannot be settled within one year of the accident.

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